|Shigeki Koizumi||Kenji Minakata||Kazuhiro Yamazaki|
|Hisashi Sakaguchi||Kyokun Uehara||Kazuhisa Sakamoto|
|Hiroomi Nishio||Tomohiro Nakata||Tadashi Ikeda|
（Department of Cardiovascular Surgery, Kyoto University Hospital＊, Kyoto, Japan）
Background:Connective tissue disease（CTD）is an idiopathic autoimmune disorder which causes systemic chronic inflammation. Inflammation causes various cardiovascular diseases. Systemic steroid use, which is usually the sole treatment for CTD, also causes arteriosclerosis. Although cardiovascular surgery is often necessary in patients with CTD, preexisting multiple organ dysfunction related to CTD, in addition to systemic administration of steroids or other immunosuppressants, is thought to increase the risk of surgery. However, little is known about how the disease process of CTD influences early and late cardiovascular surgery outcomes. Methods:To better understand these issues, we reviewed 31 patients with CTD（study group）and compared their outcomes to those of other patients（control group）who underwent cardiovascular surgery at our institution between April 2008 and November 2013. Results:There were 26 women and 5 men, and the average age was 64.4±16.7 years. CTD types included rheumatoid arthritis in 7 patients, systemic lupus erhythematosus in 6, aortitis syndrome in 6, polymyalgia rheumatica in 3, scleroderma in 3, polymyositis in 3, and others. The procedures included 10 valve cases, 10 coronary artery bypass grafting（CABG）or CABG-valve combination cases, and 11 isolated or complicated thoracic aortic surgery cases. Prior to undergoing these procedures, 24 patients（77.4%）were treated with steroids and/or immunosuppressant, and 6 patients had been diagnosed with interstitial pneumonia in the study group. Moreover, the rate of peripheral artery disease and carotid artery stenosis in the study group was significantly higher than that in the control group. There were no perioperative deaths in the study group. There were no significant differences in terms of major complications such as ischemic events, infection, acute kidney injury, lung injury, and others between the groups. We conducted a follow-up survey for the study group with an average period of 27.8±16.0 months. During the follow-up period, there were 4 late deaths. In addition, 8 patients required readmission, 6 for cardiovascular events and 2 for poor wound healing. All the survivors in the study group showed improved cardiac function and were in the NYHA functional class I and II. Conclusion:Cardiovascular surgery for patients with CTD can provide acceptable early and mid-term results.
Jpn. J. Cardiovasc. Surg. 46:101-106（2017）
Keywords：connective tissue disease;cardiovascular surgery;complication;arteriosclerosis;steroid
|Takahiko Masuda||Masaki Hata||Kazuhiro Yamaya|
|Tomoyuki Suzuki||Naoya Terao|
（Department of Cardiovascular Surgery, Sendai Kosei Hospital＊, Sendai, Japan）
A 75-year-old man who presented with fever and cough was given a diagnosis with active pulmonary valve endocarditis and transferred to our institution. Blood cultures were positive for Enterococcus faecalis, and transthoracic echocardiography showed a mobile vegetation attached to the pulmonary valve. Despite an 8-week treatment with antibiotics, a relapse of the infection required surgery. During the surgical procedure, we found that the vegetation had destroyed all of the pulmonary valve leaflets. After excising the pulmonary valve leaflets, we implanted a bioprosthetic valve and closed the pulmonary artery with autologous pericardium. The patient completed a 6-week course of intravenous antibiotics and was discharged on postoperative day 68. Postoperative transthoracic echocardiography demonstrated an adequate effective orifice area index. Our case report of isolated pulmonary valve endocarditis without predisposing factors is rare. The implantation of a bioprosthetic valve and enlargement with an autologous pericardial patch is an effective option for achieving a satisfactory hemodynamic profile.
Jpn. J. Cardiovasc. Surg. 46:107-110（2017）
Keywords：pulmonary valve;infective endocarditis;pulmonary valve replacement
|Mamoru Hamuro||Kenji Yamamoto||Tomoyuki Yamada|
（Department of Cardiovascular Surgery, Okamura Memorial Hospital＊, Shizuoka, Japan）
Chylorrhea is a rare complication after cardiothoracic surgery, occurring in 0.5-2% of patients. It is extremely rare after coronary artery bypass grafting. The initial management of chylorrhea is conservative, but if it is unsuccessful, surgical intervention is indicated. Recently, some cases treated with octreotide have been reported. We report two cases of chylorrhea after internal thoracic artery harvest treated with octreotide.
Jpn. J. Cardiovasc. Surg. 46:111-113（2017）
Keywords：chylorrhea;octreotide;CABG;internal thoracic artery
|Eisaku Nakamura||Kouichiro Ochiai||Yukie Shirasaki|
|Hirohito Ishi||Koji Furukawa||George Endo|
（Division of Cardiovascular Surgery, Department of Surgery, University of Miyazaki＊, Miyazaki, Japan）
For A 38-year-old male diagnosed a congenital complete atrioventricular block in the neonatal period, epicardial lead and pacemaker was implanted through left thoracotomy. Although we tried to implant a pacemaker through the subclavian vein as an adult, it was unsuccessful because of obstruction of the bilateral subclavian vein. For this reason, we performed a pacemaker implantation with transatrial-endocardial lead through the right thoracotomy due to save the generator electric power. This is one of the useful techniques for cases with obstruction of the upper extremity vein.
Jpn. J. Cardiovasc. Surg. 46:114-118（2017）
Keywords：congenital complete atrioventricular block;pacemaker implantation;transthoracic transatrial approach;obstruction of bilateral subclavian vein
|Yuki Kuroda||Yoshio Arai||Keisuke Hakamada|
|Masafumi Kudo||Takashi Tsuji||Hiroo Teranishi|
|Hideki Tsubota||Michiya Hanyu|
（Department of Cardiovascular Surgery, Kokura Memorial Hospital＊, Kita-Kyushu, Japan）
An 84-year-old woman with severe aortic stenosis（AS）and coronary artery disease（CAD）was admitted repeatedly with syncope and heart failure. Due to her comorbidities, concomitant transapical transcatheter aortic valve replacement（TAVR）and off-pump coronary artery bypass grafting（OPCAB）were performed. She did well postoperatively. CAD is often found concurrently in patients presenting with severe symptomatic AS. Concomitant TAVR and OPCAB is considered as a less invasive and more feasible treatment option in high-risk patients.
Jpn. J. Cardiovasc. Surg. 46:119-121（2017）
Keywords：aortic stenosis;transcatheter aortic valve replacement;off-pump coronary artery bypass grafting
|Takumi Kawase||Yasuyuki Bito||Takashi Murakami|
|Mitsuharu Hosono||Yasuo Suehiro||Shinsuke Nishimura|
|Shigefumi Suehiro||Toshihiko Shibata|
（Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine＊, Osaka, Japan）
A 76-year-old woman required aortic valve replacement due to severe aortic stenosis. She had a huge thyroid cancer, which invaded the innominate and left internal jugular veins. We planned a two-stage operation:the first involved aortic valve replacement;and the second involved operation of the thyroid cancer. To avoid median sternotomy, we adopted the right parasternal approach. A 7-cm right parasternal skin incision was made. The third and fourth costal cartilages were cut and bent into the right thoracic cavity, without removal of the ribs. The postoperative course was uneventful, and second operation was performed via the median sternotomy approach on postoperative day 53. The right parasternal approach can be used as an alternative when sternotomy is unsuitable in cases of aortic valve replacement.
Jpn. J. Cardiovasc. Surg. 46:122-125（2017）
Keywords：right parasternal approach;minimally invasive cardiac surgery;aortic valve replacement
|Takao Miki||Toru Takahashi||Jun Mohara|
（Department of Thoracic and Visceral Organ Surgery, Gunma University Graduate School of Medicine＊, Maebashi, Japan）
A 66-year-old man experiencing fever and dyspnea was transferred to our hospital 2 years ago. He had been on hemodialysis for 30 years due to chronic renal failure and was observed as having aortic stenosis for 5 years. Severe mitral regurgitation and complete atrioventricular block caused by infective endocarditis（IE）were noted. Thus, he emergently underwent double-valve replacement（DVR）and pacemaker implantation. The range of infection extended widely to the right atrium and atrioventricular septum beyond the mitral annulus. The infection was suppressed by perioperative antibiotic therapy. Transthoracic echocardiography（TTE）revealed a cavity approximately 30mm in diameter in the left ventricle, which was located under the mitral annulus, and it extended to the right atrium 3 months after the operation. A diagnosis of left ventricular pseudoaneurysm associated with IE was then made. Because of progressive expansion of the aneurysm, we performed another operation 2 years after the previous one. The pseudoaneurysm was located in the region of the Koch’s triangle, which indicated that it was caused by mitral annular abscess. We closed the orifice of the aneurysm approximately 20mm in diameter with a polyester patch with a diameter of 35mm. Postoperative TTE showed that the pseudoaneurysm was thrombosed and had no blood flow. Pathological examination of the wall of the pseudoaneurysm revealed that it consisted of fibrous tissues without myocardium. We encountered a rare case treated by patch closure for the left ventricular pseudoaneurysm after DVR associated with IE.
Jpn. J. Cardiovasc. Surg. 46:126-129（2017）
Keywords：left ventricular pseudoaneurysm;infective endocarditis;mitral annular abscess;patch closure
|Ken-ichiro Takahashi||Yuji Maruyama||Takahide Yoshio|
|Motoko Morishima||Takashi Nitta|
（Department of Cardiovascular Surgery, Nippon Medical School＊, Tokyo, Japan）
A 74-year-old woman presented to our hospital with complaints of dysphagia. On examination, we diagnosed extensive thoracic aortic aneurysm and esophageal compression due to a descending thoracic aortic aneurysm. We planned a two-stage approach for repairing the extensive thoracic aortic aneurysm;the first stage involving the repair of the ascending and arch segments, and the second stage involving the repair of the descending aorta. In the first stage, we performed the Bentall procedure and total arch replacement with a long elephant trunk. Following this, her dysphagia resolved, although the size of the descending aortic aneurysm was the same as that before the procedure（49mm in diameter). We decided to treat her conservatively in the outpatient clinic without the second stage, because the descending aorta was asymptomatic and not sufficiently large. One year later, she presented with a sudden recurrence of dysphagia and swelling of buttocks. She was diagnosed with an expansion of the descending aortic aneurysm（62mm in diameter）and a hematoma in the gluteal muscle due to aneurysm-induced disseminated intravascular coagulation（DIC). After emergency admission, she underwent a successful thoracic endovascular aortic repair and was discharged following a smooth recovery from dysphagia and aneurysm-induced DIC. We report this case along with a review of the literature.
Jpn. J. Cardiovasc. Surg. 46:130-133（2017）
Keywords：thoracic aortic aneurysm;two-stage repair;elephant trunk;DIC;TEVAR
|Masataka Yoda||Kuniki Nakashima||Kazutomo Minami|
（Department of Cardiovascular Surgery, Cardiovascular Hospital of Central Japan＊（Kitakanto Cardiovascular Hospital), Shibukawa, Japan）
Autosomal dominant polycystic kidney disease（ADPKD）is primarily caused by not only renal failure but also systemic diseases, including cysts of other systemic organs, and vascular dissection or aneurysm. To make matters worse, life-threatening aortic diseases are associated with ADPKD in some cases. However, only a few cases were reported ADPKD-associated with aortic dissection in the international literature. A 37-year-old woman was hospitalized due to Stanford type A acute aortic dissection and moderate aortic valve regurgitation. The entry of the aortic dissection was located at the aortic arch. The sinus of Valsalva was dilated to 50 mm. She had a family history, her grandfather suffered ADPKD, and also her mother had ADPKD too. Her mother died of subarachnoid hemorrhage at 44 years old. We performed urgent aortic root replacement, graft replacement of ascending aorta and aortic arch. The blood flow of the right carotid artery reduced after closing the thorax. The echo showed the false lumen pressed the true lumen in the common carotid artery, and we reconstructed the carotid artery. We clamped the common carotid artery simply, we fixed the intimal flap and re-sutured right carotid artery. She did not require dialysis after the procedure, and she was discharged on the 14th postoperative day. Pathological finding of the aortic wall showed the dissection of the media alone. No findings such as aortitis or cystic medial necrosis were recognized.
Jpn. J. Cardiovasc. Surg. 46:134-138（2017）
Keywords：autosomal dominant polycystic kidney disease;thoracic aortic dissection;aortic root replacement;total aortic arch replacement;carotid artery reconstruction
|Toru Mizumoto||Satoshi Teranishi||Hisato Ito|
|Yasuhiro Sawada||Naoki Yamamoto||Shinji Kanemitsu|
（Department of CardioThoracic Surgery, Anjo Kosei Hospital＊, Anjo, Japan, and Department of CardioThoracic Surgery, Mie University Hospital＊＊, Mie, Japan）
A 50-year-old man with an extensive thoracic aortic aneurysm underwent staged surgery which consisted of preceding total aortic arch replacement with the frozen elephant trunk technique using J Graft Open Stent Graft●R, followed by open thoracoabdominal aortic aneurysm repair. During the second operation, the descending aorta was cross clamped along with the preexisting stent graft, and Dacron graft was anastomosed directly to the stent graft using a running 4-0 monofilament suture. The anastomosis site was then covered with a short piece of Dacron graft identical with the stent graft in size to secure hemostasis. We herein discuss our approach in this complex case, focusing on prevention of inadvertent events such as deformation of the preexisting stent graft and unexpected bleeding.
Jpn. J. Cardiovasc. Surg. 46:139-142（2017）
Keywords：J Graft Open Stent Graft●R;open surgery;direct graft anastomosis
|Masayuki Fujisaki||Yoshihiro Suematsu||Takafumi Inoue|
|Satoshi Nishi||Akihiro Yoshimoto||Sei Morizumi|
（Department of Cardiovascular Surgery, Tsukuba Memorial Hospital＊, Tsukuba, Japan）
Spontaneous rupture of the thoracic aorta without trauma, aneurysm or dissection is a rare but fatal disease. We reported successful endovascular aortic repair of thoracic aortic spontaneous rupture in 3 patients. Generally, it is difficult to accurately identify the rupture site in the spontaneous rupture. However, by detailed planning based on the data of preoperative CT images, thoracic endovascular aortic repair（TEVAR）can be successfully performed, like surgical repair of spontaneous rupture of the distal aortic arch or descending thoracic aorta. TEVAR should be considered as a first-line therapy, especially, in patients with advanced age or significant comorbidities.
Jpn. J. Cardiovasc. Surg. 46:143-147（2017）
Keywords：spontaneous rupture of the thoracic aorta;AAS;endovascular aortic repair;TEVAR